This was a 50-year-old male smoker with a history of hyperlipemia, previous stent, on Plavix and ASA who presented for chest pain to the ER. It was his second visit for chest pain. He was chest pain-free with one NTG SL, and his first troponin was negative.

There was some discussion about sending him home if his second troponin was normal. Was this the right thing to do? It was tempting to rely on the patients’ recent stress test as it was done 10 days prior. But, they are not always accurate. If a patient has significant risk factors, especially previous stent patients, and smokes, they have a high index of suspicion for new diseases.

This patient has a classic “Wellen’s Sign” here, and there is a high mortality rate associated with sending a patient home with this sign. It usually means they have a high-grade LAD occlusion that will require intervention (PCI). The cardiologist was called, and he came in took him to the cath lab, and he required a stent in his LAD due to an 80% occlusion noted.

The second troponin came back while he was in the cath lab and was 8, which was elevated. Wellen’s sign is found in V2 and V3 (can extend into V4, V5, V6 as well). You will see inverted or biphasic T waves in V2 and V3. The patient can be pain-free at the time of the ECG.

They have a high risk of dying within the next week. This is definitely a “Can’t Miss EKG Finding” that the EKG machine software won’t always pick up.

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